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Nasopharyngeal Angiofibroma

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1 Nasopharyngeal Angiofibroma
Dr. Vishal Sharma

2 Definition Benign tumor of nasopharynx (?), locally invasive, extremely vascular & occurs in adolescent males. Hamartomatous nidus of vascular tissue, dependent on testosterone. Synonyms: nasopharyngeal fibroma, angiofibroma

3 Site of origin Arises in posterior nasal cavity, near superior
border of sphenopalatine foramen

4 Sphenopalatine foramen

5 Pathology Gross: Sessile, bi-lobed, rubbery, red-pink or gray in colour. Histology: Encapsulated, composed of vascular tissue & fibrous stroma. Vessels are thin-walled, lack elastic fibers & smooth muscle (this leads to uncontrolled bleeding).

6 Histopathology

7 Small tumour

8 Nasal cavity

9 Nasal cavity & P.N.S.

10 Nasopharynx

11 Pterygopalatine fossa

12 Infratemporal fossa

13 Infratemporal fossa

14 Cheek

15 Orbit

16 Sphenoid sinus

17 Middle cranial fossa

18 Pituitary & Cavernous sinus

19 Spread Anterior: Nasal cavity + paranasal sinus Posterior: Nasopharynx
Lateral: goes to Pterygopalatine fossa  1. Infratemporal fossa  cheek 2. Inferior orbital fissure  orbit

20 Spread Superior: 1. Sphenoid sinus  Middle cranial fossa
 Cavernous sinus  Optic chiasma  Pituitary fossa 2. Skull base

21 Symptoms 1. Nasal obstruction (80-90%) with denasal
speech (rhinolalia clausa) 2. Epistaxis (50-60%): Persistent, Painless, Profuse, Paroxysmal, Unprovoked 3. Headache (25%) 4. Facial swelling (20%): cheek & palatal swelling

22 Facial swelling

23 Signs 1. Nasal or Nasopharyngeal mass (80%) 2. Frog-face deformity:
proptosis + nasal bridge broadening 3. Otitis media with effusion: due to E.T. blockage 4. Trismus: involvement of pterygoid muscle 5. Involvement of II, III, IV, VI cranial nerve

24 C.T. scan P.N.S. with contrast
Extent of tumor Anterior bowing of posterior maxillary wall (Miller Holman’s antral sign) Tumor enhancement Bone destruction

25 Other Investigations  M.R.I.: for intra-cranial involvement
 Digital Subtraction Angiography (D.S.A.): a. extent of tumor b. tumour blush (due to increased vascularity) c. feeding arteries for embolization  Biopsy: contraindicated (profuse bleeding)

26 Magnetic Resonance Imaging

27 D.S.A. before embolization

28 D.S.A. after embolization

29 Differential diagnosis
Rhabdomyosarcoma Antrochoanal polyp Teratoma Dermoid Encephalocoele Inverting papilloma Squamous cell carcinoma

30 Staging Stage I: Tumor limited to nasal cavity or
nasopharynx with no bony destruction Stage II: Tumor invading pterygopalatine fossa or paranasal sinuses Stage III: Tumor invading infratemporal fossa or orbit or parasellar region Stage IV: Tumor invading cavernous sinus or optic chiasma or pituitary fossa

31 Pre-op reduction of tumor vascularity
1. Embolization of feeding arteries: with Gelfoam 2. Oestrogen therapy: Diethylstilbestrol ( mg orally t.i.d. for wk) 3. Testosterone receptor blocker: Flutamide 4. Pre-operative radiotherapy 5. Cryotherapy of tumor

32 Trans-palatal approach

33 Trans-palatal approach

34 Trans-palatal approach

35 Sardana’s approach

36 Endoscopic approach

37 Lateral rhinotomy approach

38 Lateral rhinotomy approach

39 Midfacial degloving

40 Denker’s incision Caldwell Luc incision extended medially till midline

41 Le Fort 1 osteotomy

42 Infratemporal fossa approach

43 Anterior subcranial approach

44 Surgical approaches 1. Trans-palatal approach (Wilson)
small tumour in nasopharynx 2. Sublabial + Trans-palatal approach (Sardana) large tumour of nose + PNS + nasopharynx 3. Intranasal endoscopic approach small tumour in nose / PNS / nasopharynx

45 Surgical approaches 4. Transmaxillary approach via:
 Extended lateral rhinotomy incision  Midfacial degloving incision  Denker’s extended Caldwell-Luc incision  Le Fort 1 osteotomy approach Done for extension into pterygopalatine fossa

46 Surgical approaches 5. Infratemporal fossa approach (Fisch) extension into infratemporal fossa 6. Anterior subcranial approach intracranial & orbital extension 7. Image-guided, endoscopic, laser-assisted removal (latest): small / medium size tumors

47 Surgical specimen

48 Surgical specimen

49 Proton Stereotactic Radiation Therapy (P.S.R.T.)
Synonym: Gamma knife surgery Used for: 1. Intracranial extension 2. Recurrence after surgery Single relatively high dose of radiation delivered precisely to a small area to kill tumor cells Minimal injury to adjacent nerves & brain tissue

50 Stereotactic Radiotherapy

51 Thank You

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